What is the management approach for a patient with atrial fibrillation (a-fib) undergoing mastoidectomy?

Management of Atrial Fibrillation in Patients Undergoing Mastoidectomy

Continue uninterrupted oral anticoagulation throughout the perioperative period for mastoidectomy in patients with atrial fibrillation who have an elevated thromboembolic risk (CHA₂DS₂-VASc score ≥2 in men or ≥3 in women), as mastoidectomy is a low-to-moderate bleeding risk procedure that does not typically require anticoagulation interruption. 1

Preoperative Anticoagulation Assessment

Risk Stratification

• Calculate the CHA₂DS₂-VASc score to determine thromboembolic risk: patients with scores ≥2 (men) or ≥3 (women) require anticoagulation regardless of surgical timing 1, 2
• The CHA₂DS₂-VASc score is superior to older scoring systems and more clearly defines which patients require anticoagulation, particularly identifying high-risk women who may have lower CHADS₂ scores 3

Anticoagulation Continuation Decision

• Uninterrupted anticoagulation is the preferred approach for most non-cardiac surgeries with low-to-moderate bleeding risk, including ear procedures like mastoidectomy 1
• DOACs (apixaban, dabigatran, edoxaban, rivaroxaban) are preferred over warfarin for perioperative management due to their shorter half-lives and more predictable pharmacokinetics 1, 2
• Mastoidectomy does not fall into the high-bleeding-risk category that would mandate anticoagulation interruption 1

Perioperative Anticoagulation Management

For Patients on DOACs

• Continue DOAC therapy without interruption through the perioperative period for mastoidectomy 1
• If the surgical team insists on brief interruption: hold the DOAC for 24 hours (1-2 doses) before surgery for standard renal function, then resume 6-8 hours post-procedure if hemostasis is adequate 1
• Use full standard doses unless specific dose-reduction criteria are met (advanced age with low body weight, renal impairment) 1

For Patients on Warfarin

• Consider switching to a DOAC if the patient has poor INR control (time in therapeutic range <70%) or if perioperative management would be simplified 1
• If continuing warfarin: maintain INR 2.0-3.0 and proceed with surgery if INR is in therapeutic range 1, 2
• Warfarin must be continued in patients with mechanical heart valves or moderate-to-severe mitral stenosis, as DOACs are contraindicated 1, 2

Rate Control During Perioperative Period

Medication Management

• Continue beta-blockers throughout the perioperative period in all patients without contraindication, as withdrawal increases risk of postoperative atrial fibrillation 1
• Beta-blockers are recommended for rate control in patients with any ejection fraction 1
• Alternative rate control agents (diltiazem, verapamil) can be used if LVEF >40% and beta-blockers are contraindicated 1

Prophylaxis Against Postoperative Atrial Fibrillation

• While prophylactic amiodarone reduces postoperative AF after cardiac surgery, it is not routinely indicated for non-cardiac procedures like mastoidectomy 1, 4
• Maintaining beta-blocker therapy is the primary prophylactic measure 1, 5

Management of New-Onset or Worsening Atrial Fibrillation Perioperatively

Acute Management

• Electrical cardioversion is indicated only if hemodynamic instability develops 1
• For hemodynamically stable patients: prioritize rate control with intravenous beta-blockers (if LVEF preserved) or digoxin (any ejection fraction) 1
• Avoid pharmacological cardioversion in the immediate perioperative period unless the patient is highly symptomatic and hemodynamically stable 1

Anticoagulation for New-Onset AF

• If AF duration is >24 hours, provide therapeutic anticoagulation for at least 3 weeks before any elective cardioversion 1
• For new-onset AF in the perioperative setting: initiate anticoagulation based on CHA₂DS₂-VASc score, not on whether the AF is "postoperative" or "temporary" 1, 2
• Heparin can be used for immediate anticoagulation if oral agents were held perioperatively 6

Special Considerations

Bleeding Risk Management

• Modifiable bleeding risk factors should be optimized (hypertension control, avoidance of NSAIDs, correction of anemia), but bleeding risk scores should not be used to withhold anticoagulation 1
• The surgical team should use meticulous hemostatic technique rather than requesting anticoagulation cessation 1

Antiplatelet Therapy

• Avoid combining anticoagulants with antiplatelet agents unless the patient has had a recent acute coronary syndrome or stent placement requiring dual antiplatelet therapy 1
• Antiplatelet therapy alone is never adequate for stroke prevention in AF 2, 7

Long-Term Management

• Continue anticoagulation indefinitely based on CHA₂DS₂-VASc score, regardless of whether the patient remains in sinus rhythm postoperatively 1
• Postoperative AF, even if it resolves, does not change the underlying thromboembolic risk that necessitated anticoagulation 4, 5

Common Pitfalls to Avoid

• Do not discontinue anticoagulation for mastoidectomy based solely on surgeon preference without objective assessment of bleeding risk 1
• Do not stop beta-blockers perioperatively, as this significantly increases risk of postoperative AF 1, 5
• Do not assume postoperative AF is "temporary" and withhold anticoagulation—base decisions on CHA₂DS₂-VASc score 1, 4
• Do not use bridging anticoagulation with heparin for patients on DOACs undergoing low-bleeding-risk procedures, as this increases bleeding without reducing thromboembolism 1